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Pediatric In Training
History and Physical Examination Assessment
PREAMBLE
The requirement for Pediatric residency training programs to perform and document by
observation an assessment of each resident's history and physical examination (HPE) abilities is in
response to the following:
a) the major importance of HPE in the day-to-day activities of Pediatricians
b) the necessity to insure that HPE skills are rigorously evaluated during Pediatric training
c) the necessity of eliminating non-standardized patients from the Royal College of Physicians
and Surgeons of Canada (RCPSC) Pediatric examination leading to Certification
d) the impracticality and ethical difficulties of using young children as standardized patients
e) the value of detailed information on HPE to be included with the specialty-specific Final InTraining Evaluation Report (FITER) and Core In-Training Evaluation Report (CITER)
f) the need to have the same assessment and examination process for all residents (French and
English)
INTRODUCTION
By using this standardized form, the Pediatric residency programs will ensure that the resident's
history and physical examination abilities are assessed in an organized manner. Each assessment
will be observed and evaluated by two assessors, who may be members of the Pediatric
Examination Board or Examination Committee or its subcommittees, and/or should be familiar
with the examination process (e.g., a former examiner, or someone who has completed a RCPSC
workshop or similar activity). Each Department of Pediatrics will be responsible for selecting as
assessors a cadre of Pediatricians who will be appointed for a three-peat renewable term. One of
the assessors will be familiar with the patient while the other will have no knowledge of the
patient.
The complexity of patient problems should represent the type of patients that are under the care
of consultant general Pediatricians. The standard to be used is the acceptable competency level
expected of a consultant general Pediatrician functioning in a community setting such as a midsized city without a tertiary Pediatric centre.
PROCESS
A period of 60 minutes will be allotted to the resident to perform an appropriately focused yet
comprehensive history and physical examination. This will be followed by a five minute period to
allow the resident to prepare a case presentation. The case summary and a prioritized patient
problem list will be presented by the resident in a ten minute period.
Each assessor will independently evaluate by observation the resident's performance. The
assessment form should be completed and signed by the two assessors and the resident. The
assessment form will be submitted to the RCPSC with the Final In-Training Evaluation Report
(FITER) and will be retained in the resident's file.
2006 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright 2006 The Royal College of Physicians and
Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director. Written permission from the Royal
College is required for all other uses. For further information regarding intellectual property, please contact: documents@royalcollege.ca. For questions regarding the use of this document, please
contact: credentials@royalcollege.ca.
Page 1 of 3
Pediatric History and Physical Examination
A mastery learning approach will be used in which a resident may repeat the assessment until a
satisfactory performance is achieved. Assessments will occur in the second half of the third core
year of training and must be successfully completed before the completion of the fourth and final
year of required residency training.
Candidates not trained in Canada but whose training has been approved by the RCPSC will be
assessed by their home program using the assessment forms which will later be included with the
FITER.
METHOD
1. Patients must be:
- selected by the program;
- having at least one major medical problem (no more than three major medical and/or
social problems) of a complexity sufficient to require care by a consultant general
Pediatrician;
- known to only one of the assessors and unknown (unfamiliar) to the resident;
- able to provide a reliable history or be accompanied by an individual who may provide the
patient history.
2. Assessors must be:
- familiar with the assessment process and understand the acceptable competency level
expected of a consultant general Pediatrician;
- selected by the Department of Pediatrics in each university;
- aware of the examination process leading to certification;
- appointed by the Department of Pediatrics for a three-year renewable term;
- Pediatricians other than the Program Director.
3. Residents will:
- be under observation by two assessors while taking the history and performing the
physical examination;
- have a maximum of 60 minutes to perform the history and physical examination
(additional time may be allotted only if an interruption occurred during the 60 minutes)
- be given five minutes to prepare for the case presentation;
- will present within a ten minute period a case summary and a prioritized patient problem
list, including a limited differential diagnosis, where applicable, for only the major problem.
4. Standardized documentation forms will be:
- completed by the two assessors;
- signed by the two assessors and the resident;
- included with the FITER and/or CITER and submitted to the Royal College.
Page 2 of 3
5. Assessments will:
- be scheduled in advance and, when possible, will occur at a prearranged time and place;
- occur in the second half of the third core year of training and may be repeated until a
satisfactory performance is achieved (mastery learning);
- be successfully completed before the completion of the fourth and final year of required
residency training.
Editorial revisions July 2012
Page 3 of 3
Assessment of History and Physical Examination

Skills in Pediatrics
(Please Print)
Resident:
University:
Patient Characteristics (Age/Sex)
Start:
Finish:
Patients Problem(s):
INTERVIEWING
YES
BORDERLINE
NO
N/A
Introduce him/herself and explain the situation, use

patient's name
Attempt to establish rapport with parent and child
Did the resident:
Direct questions when appropriate to child

Use words that are easily understood; avoid medical
jargon
Ask open-ended questions in history-taking
Ask specific closed questions when necessary
Listen attentively to patient/parent
Display empathy and sensitivity
Display awareness of and respond to family's
concerns / agenda
Have acceptable non-verbal communication
Close the interview appropriately: summary, parents'
concerns
Rate this resident's interviewing skills "at the level of a consultant general pediatrician:
Satisfactory - meets expectations
Borderline (* comment required)
Unacceptable - below expectations (* comment required)
Comments:
Page 1 of 7
Identification Number: _____________________________
160
HISTORY-TAKING
YES
BORDERLINE
NO
N/A
Infancy
Infant feeding (breast, formula, solids)
Sleeping problems, colic, etc.
Development
Gross motor skills
Fine motor skills
Language skills
Social skills
Immunizations
Routine immunizations
Other
Did the resident obtain a pertinent history including

the following:
Present Illness
Chief complaint(s)
Onset of illness
Thorough description of chief complaint(s)
Symptoms associated with chief complaint
Progress through the course of the illness
Family's management of the illness
Define current status of illness
Contact with medical personnel: tests, treatment
offered
For an infectious disease: possible contacts, day care,
travel
Family History
Parents' age, consanguinity, health/illness relevant to
child's illness
Siblings: sex, age, health and illness relevant to
child's illness
Other extended family illness as appropriate
Mother's Pregnancy, Birth, Newborn Period
Mother's health during pregnancy, illness, drugs,
alcohol, cigarettes
Birth weight, gestational age
Neonatal problems: jaundice, cyanosis / respiratory
problems, seizures, birth anomalies, low Apgar score
Page 2 of 7
Past Illness
Past illness
Allergies
Medications
Hospitalizations/operations/injuries
Functional Inquiry / Review of Systems
Appropriate and comprehensive review of systems
Organized review of systems
Psycho-Social
Parents' occupations, family living situation
Drug or alcohol abuse, smoking in child / family
Impact of the illness on the family
Impact of the illness on the child's activities of daily
living
School progress, physical and social activities,
interests, peer relationships
Risk-taking, sexual behaviours, nutrition and eating
habits
Specific concerns of the family
160
YES
BORDERLINE
NO
N/A
Overall History-taking * A No or Borderline rating in any of the following items in this section
constitutes borderline/unacceptable, PLEASE COMMENT BELOW.
The primary concerns of the patient/family, prioritization of problems
An overview of the problem in context to the child and family's life
Sufficient information to adequately manage the major problems
Rate this resident's history-taking "at the level of a consultant general pediatrician":
Comments:
Page 3 of 7

PHYSICAL EXAMINATION
Did the resident perform a physical exam that
included:
General
Wash hands
Obtain height/length, weight, head circumference
Obtain vital signs: pulse, respiratory rate, blood
pressure
Pause to observe the whole child: activity,
appearance, hydration
Head and Neck Exam
Head size, shape, fontanels, scalp
Eye movements, abnormalities, ophthalmoscopic exam
Ears - otoscopic exam
Mouth, teeth, palate, pharynx, nose
Palpate neck for cervical lymph nodes, thyroid gland,
masses
Respiratory System
Observation of chest size, shape, movement
Ausculation of chest - comparing both sides; front and
back
Percussion of chest - diaphragm levels, both sides,
front and back
Cardiovascular System
Peripheral exam -femoral pulses, clubbing, capillary
refill
Palpate precordium
Auscultate four areas of precordium and back when
appropriate
Abdominal Exam
Observe size, distention, shape and look for
abnormalities
Gentle palpation for tenderness
Specific palpation for liver, spleen, kidneys
Specific palpation for other masses, ascites
Auscultation of abdomen
Percussion of abdomen
Observation/examination of external genitalia, for
herniae
Indicate the need for a rectal examination
Extremities
Observe for any deformities, obvious joint
abnormalities
Observe gait
Examine relevant joints for swelling, tenderness,
range of movements
Examine hips for congenital dysplasia
160
YES
BORDERLINE
NO
N/A
Page 4 of 7
160
YES
BORDERLINE
NO
N/A
Skin Exam
Observe overall skin for lesions or abnormalities
Neurologic Exam
Assess cranial nerves
Assess level of consciousness and cognitive ability
Assess appropriate motor power, tone, coordination
Assess reflexes / symmetry
Assess vision, hearing, sensation as appropriate
Observe balance, stance, gait
Test for scoliosis
Developmental Assessment
Assess developmental and cognitive skills, to
corroborate history from parent
Overall Physical Examination * A No or Borderline rating in any of the following items in this
section constitutes borderline/unacceptable, PLEASE COMMENT BELOW.
A focused, thorough, problem oriented physical exam
Opportunistic flexible approach in examining the child
Appropriate exam for time, situation and parent/child comfort
Respectful of child, age appropriate
Correct physical examination maneuvers
Rate this resident's physical examination skills "at the level of a consultant general
pediatrician":
Comments:
Page 5 of 7
160
PRESENTATION OF CASE SUMMARY

AND PROBLEM - (10 minutes)
Did the resident:
Present accurate data from history and physical
examination
Present succinctly the important positive and
negative points
Present a complete problem list
Present a prioritized problem list
Present a good evaluation of the child's problem with
a differential diagnosis of the major problem where
applicable
YES
BORDERLINE
NO
N/A
Rate this resident's presentation of case summary skills "at the level of a consultant general
pediatrician":
Comments:
Overall
Did the resident demonstrate any errors of omission or commission that would:
i. endanger the child or put the child at risk (i.e., being physically rough with the child or leave
the child unattended)
ii. compromise the relationship with the child (i.e., being rude or disrespectful, not paying
attention to the modesty of the child)
iii. compromise the relationship with the parent (i.e., being disrespectful of the parent, making
inappropriate sexual, racial or judgmental comments)
iv. lead to an incorrect or inadequate assessment of the child's pediatric problems (i e., missing
a major abnormality on history or physical examination)
No
Yes (*Comment required)
Comments:
Page 6 of 7
160
OVERALL EVALUATION
Rate this resident's performance "at the level of a consultant general pediatrician":
Meets expectations
Below expectations
Comments:
Strengths:
Weaknesses:
******************************************************************************
Observer (1)
(Please Print)
(Signature)
Observer (2)
(Please Print)
(Signature)
This is to attest that I have read this assessment:
Resident (Signature)
Date
Page 7 of 7
Pediatrics in-Training History and Physical

Examination (HPE) Assessment
OVERALL PERFORMANCE
Name:
_____
University:
This resident completed the standardized assessment of history-taking, physical examination and
synthesis of a patient's problems. A complete record is in the resident's file. The following is a
summary of the overall performance with comments on strengths and weaknesses summarized
by the program director.
Overall Performance
Satisfactory
Below Expectations
Strengths:
Weaknesses:
Date
Name of Program Director
Signature
Date
Name of Resident
Signature
* This is to be returned with the FITER

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Pediatric In Training

History and Physical Examination Assessment

Editorial revisions July 2012

Assessment of History and Physical Examination

Patient Characteristics (Age/Sex)

Introduce him/herself and explain the situation, use

Attempt to establish rapport with parent and child

Did the resident:

Direct questions when appropriate to child

Identification Number: _____________________________

Did the resident obtain a pertinent history including

Identification Number: _____________________________

Identification Number: _____________________________

Identification Number: _____________________________

Test for scoliosis

Identification Number: _____________________________

PRESENTATION OF CASE SUMMARY

Yes (*Comment required)

Identification Number: _____________________________

This is to attest that I have read this assessment:

Pediatrics in-Training History and Physical

Name of Program Director

* This is to be returned with the FITER

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